Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.

Expanding Treatment Options for Stress Urinary Incontinence

GOALTo provide primary care physicians and urologists with information on the most recent developments regarding the treatment of stress urinary incontinence.

TARGET AUDIENCEThis activity is designed for primary care physicians and urologists. No prerequisites required.

LEARNING OBJECTIVESThe Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

Review the current epidemiologic data on the incidence and prevalence of stress urinary incontinence.

Assess the impact of stress urinary incontinence on quality of life.

Define the role of the central nervous system and neurotransmitters in lower urinary tract control.

Discuss the full spectrum of current and emerging treatment approaches and appropriate candidates for each, including conservative, pharmacologic, and surgical treatments.

ACCREDITATION STATEMENTThe Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

CREDIT DESIGNATION STATEMENTThe Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

DISCLAIMER STATEMENTThe opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Eli Lilly and Company.

Full Disclosure Policy Affecting CME Activities:As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

Ananias C. Diokno, MDChiefDepartment of UrologyWilliam Beaumont HospitalRoyal Oak, Michigan• Dr Diokno reports receiving grant and/or research support from Eli Lilly and Company and Medtronic; and serving as a consultant to Ortho-McNeil Pharmaceutical, Inc.

Notice:In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles reference the following unlabeled/unapproved uses of drugs or devices:

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Stress urinary incontinence (SUI) remains a highly prevalent condition, causing great personal distress and adversely affecting patients' overall quality of life (QOL). SUI can interfere with many routine functions that most individuals take for granted, particularly those functions that involve social interaction. The concerns, fears, and embarrassment associated with SUI gradually can turn otherwise healthy individuals into homebound patients, dependent on others for a wide range of simple tasks.

The information in this issue of Advanced Studies in Medicine reflects the latest developments in the diagnosis, evaluation, and management of SUI. The articles, prepared by leading authorities in the field of urinary incontinence, show that SUI is geographically ubiquitous, affecting populations worldwide. Both developed and developing nations report a cumulative prevalence in the millions, although wide geographic variations in prevalence exist.

In the United States, between 30% and 40% of women report a history of urinary incontinence. In most cases, stress incontinence is a component of the condition, either in the form of pure SUI or as part of the symptomatology of mixed urinary incontinence. Even after taking into account geographic variations in prevalence, stress incontinence remains a predominant feature of urinary incontinence, when pure SUI and mixed incontinence are considered together.

Although the focus of clinical management has been on SUI as a medical condition, the QOL implications have long been recognized. More than 25 years ago, the International Continence Society characterized urinary incontinence as "involuntary loss of urine that is a social or hygienic problem." The extent to which incontinence adversely affects a patient's QOL is the driving force behind the decision to seek treatment. A variety of survey instruments have been employed to assess the impact of SUI on QOL in clinical trials and in clinical practice. Though they sometimes differ regarding their approaches to assessment, the survey tools have consistently shown that SUI has a wide-ranging effect on QOL. During the 1980s and 1990s, the impact on QOL grew in prominence, as interest and participation in physical activity increased among women, who sought physician advice and intervention to minimize the effects of SUI in unprecedented numbers.

Clinicians today can offer SUI patients more treatment options than at any time in the past. Increasingly, treatment decisions can be tailored to the needs, expectations, and tolerances of individual patients. Patient education and behavior modification training, including pelvic muscle exercises, remain a major component of treatment. When practiced by motivated, adherent patients, the techniques can achieve acceptable results in many cases.

Surgery is often pursued by patients seeking a permanent solution to SUI. Although surgical procedures result in long-term improvement for most patients, findings from recent studies suggest that surgery fails to provide a cure in many instances. Substantial numbers of patients report new or recurrent symptoms (stress, urge, or retention), use of absorbent pads, concomitant use of medication, and continued adherence to behavior modification training and pelvic muscle exercises. Patient satisfaction with surgery appears to decline over time.

A variety of injectable bulking agents have been evaluated as therapy for SUI. These therapies have faced obstacles, such as loss, extravasation, absorption, biocompatibility, and migration issues. Injection therapy is less invasive than surgery, but sustained good results are generally less common.

Currently, no pharmacologic treatment has been approved by the US Food and Drug Administration for the treatment of SUI. Several types of alpha-adrenergic agonists have been used, but the agents have been associated with low rates of efficacy and unacceptable risks in some patients (including hypertension and tachycardia). Estrogens have been evaluated extensively, but in only a few controlled clinical trials. Evidence from controlled trials suggested subjective improvement but no change in objective measures of urine loss.

Recently, investigation of pharmacologic therapy for SUI has included serotonin/norepinephrine reuptake inhibitors (SNRIs). Clinical evaluation of candidate therapies has followed advances in the understanding of lower urinary tract innervation. These advances include evidence suggesting that increased concentrations of norepinephrine and serotonin may stimulate muscle activity in the perineal floor. Placebo-controlled clinical investigation of the dual SNRI duloxetine has shown significant improvement in SUI symptoms and QOL in patients treated with duloxetine.

Collectively, recent advances in understanding the origin and impact of SUI have helped to increase recognition of the magnitude of the problems posed by SUI, the potential benefits and limitations of currently available therapy, and the need for new therapeutic options. The information in this issue provides a useful summation of the current status of SUI management and is readily applicable to clinical practice.

*Professor, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland.